Comparison of two systems for stroke rehabilitation in a general hospital.

This study was designed to compare the effectiveness of stroke rehabilitation therapy in a specialized Stroke Unit with that provided on the medical service of a general hospital (Rhode Island Hospital). The 8-bed Stroke Unit is staffed by a multidisciplinary team, and a weekly conference is held for evaluation and planning. On the basis of data obtained from the hospital records, two groups of patients were studied: 224 who were treated in the Stroke Unit, and 110 who were evaluated and approved for admission to the Unit but were not accommodated. A rigid "first come, first served" policy for admission to the Unit was observed. Hypothesis testing was performed with reference to the patient's medical condition, socioeconomic status, demographic characteristics, and difficulties during hospital stay to determine whether the groups were comparable. A patient was considered to have improved if his condition decreased in severity between the time of admission to therapy and the time of discharge. Severity was rated as: mild (level one), moderate (level two), severe (level three), and profound (level four). No significant difference in rehabilitation results was found between the two treatment systems at severity levels two (moderate) and four (profound). However, the Stroke Unit attained significantly better results with level-three patients (severe stroke). This group received more sessions of physical therapy and remained in the hospital longer than did the level-three patients treated on the general medical service. Physicians referred patients selectively to the Stroke Unit, althoug the Unit had no policy of screening patients for admission, and this may have had some influence on the achievement of better results with level-three patients. Level-four patients did not do well in either setting.

How successfully can academic faculty practices compete in developing managed care markets?

The author investigated the range of competitive options available for academic faculty practices and their associated academic medical centers located in health care markets with relatively limited development of managed care plans. Using personal and telephone interviews, he studied two such markets in 1994, one in Philadelphia, Pennsylvania, and one in Atlanta, Georgia. Representatives of faculty practices in these cities were asked to assess whether their practices would be attractive or unattractive for contracting with managed care providers; eight attributes of faculty practices (e.g., specialist physicians' availability within the group; prices of services offered by the group) were used as criteria. Similarly, representatives of local managed care plans were asked to use the same criteria to indicate what they would consider attractive or not in their local faculty practices when considering a physician services contract with such a practice. In both markets, the image of the academic medical center was generally considered to be a strong asset to the faculty practices. But all sectors also agreed that the nature of practices' utilization management and what was seen as their excessive use of resources in the academic environment were causes for concern. Also, the difference between the practice patterns of managed care physicians and academic faculty physicians was regarded as a cultural one in which traditional patterns of academic training are considered inimical to fostering the prudent management of patients. The findings strongly suggest that opportunities for faculty practices to negotiate with managed care plans and help shape their areas' future health care environments still exist in developing markets throughout the United States. But even those practices with such opportunities cannot succeed without significant internal restructuring to transform themselves to successfully deal with the new world of managed care.

Organizational models of medical school relationships to the clinical enterprise.

The authors analyzed existing relationships between medical schools and clinical enterprises in order to develop models of these relationships. The conceptual framework for the models uses three variables to assess the nature of the relationships: (1) high academic control-high clinical enterprise control; (2) high academic influence-low academic influence; and (3) self-contained system-open system (i.e., the extent to which the resources needed for clinical education are provided by the relationship between the clinical enterprise and the medical school). The authors present four conceptual models of the relationship between the medical school and the clinical enterprise: (1) The "single ownership; owned integrated system" is characterized by a closed clinical delivery system owned or controlled by the academic institution. (2) The "general partner" organization emphasizes an open clinical environment in which the medical school forms alliances with clinical entities, and the school is a dominant partner. (3) The "limited partner" organization operates with an open clinical delivery system that the school relates to through affiliations and contractual relationships, and the school is a less dominant partner. (4) The "wholly owned, subsidiary" organization operates in a controlled clinical environment in which the medical school is a subsidiary of the larger integrated delivery system. Each model is presented in its pure organizational form, then augmented with descriptions of the different ways that the medical school and other components may relate to each other. Also, the advantages and disadvantages of each model for the medical school are discussed. The authors emphasize that no model is superior to the others; instead, the best choice for a medical school depends on the history, local circumstances, and leadership of the school and other organizations. The authors' intent is to assist the leaders of medical schools as they design strategies for the future relationships of their institutions.

Health care as a social good: trauma care and the "kindness of strangers".

Urban trauma centers have been shown in the medical literature to be effective resources for dealing with traumatic injury in a manner which results in demonstrated increases in survival rates. Given that much debate exists over the relative efficacy of various technological medical interventions, the acceptance and diffusion of a "proven" technology, such as trauma centers, should be assured. Yet, the significant investment of resources required to staff, equip, and maintain a trauma center, coupled with a perceived fiscal deterioration of the provision of these services, has resulted in a retreat from the concept through closure of the services.

Doctoral education in executive format, or fitting the Procrustean Bed: an exercise in organizational change.

Doctoral education in health administration has been heavily influenced by the model of the traditional academic research Doctor of Philosophy. This powerful traditional template has been appropriate for the advancement of research and scholarship in health systems administration, but not necessarily for the advancement of the field of practice. With the advent of executive doctoral programs that feature larger student cohorts, routinized curricula, and student bodies comprised of experienced professionals, the expectations for doctoral study in health systems administration are being tested as new models evolve. Faculty are reluctant to depart from the traditional doctoral forum, but will do so based upon demonstrated advantages in the area of publication opportunities, student responsiveness, and financial inducements. This paper examines the program in an executive format conforming to the existing degree offerings of the School of Public Health, and the process of balancing the traditional academic expectations with the executive format of content delivery.

The Medicare assignment controversy: the construction of public-professional conflict.

The conflict between the elderly and organized medicine over "mandatory assignment" and "balance billing" is a significant public policy issue. Considerable ideological importance has been attached to this conflict by both sides, despite the relatively modest proportion of total revenue for physician services received through balance billing in payment for care of Medicare beneficiaries. The positions of these two coalitions are examined as well as the efforts of the Physician Payment Review Commission (PPRC) to craft a public policy response. Three alternative resolutions--those adopted by Congress in 1989 on the recommendation of the PPRC, the Canadian solution, and actions taken on a state level--are then contrasted. The concentrated impact on the elderly of balance billing practices is considered as a problem, especially for elderly of limited income and resources. Justification of the practice is typically provided by the profession on the ideological grounds of preservation of professional autonomy rather than economic gain, which also reflects the current relatively limited use of balance billing; a significant majority of all claims submitted in the United States are now assigned to physicians. A continuation of the gradualist strategy of the PPRC is endorsed as the most appropriate short-range solution to these problems, which diminish in significance with a more comprehensive national health financing scheme.

Academic faculty practices: issues for viability in competitive managed care markets.

This study compares the perspectives of eighteen managed care executives and twenty-four faculty practice executives on critical policy issues related to the managed care marketplace. Market sites studied in 1994 included four major metropolitan areas: Minneapolis-St. Paul, Los Angeles, Philadelphia, and Atlanta. These markets were selected as being representative of communities with descending degrees of managed care involvement, but with significant market activity. Study participants from both managed care systems and faculty practices examined five policy issues: (1) the importance of including academic medical centers in current and future health care plans for marketing purposes; (2) the provision of clinical services that are unique to the academic medical center, that is, unavailable elsewhere in the community; (3) the degree of financial supplement that employers might pay for including an academic medical center; (4) future restructuring of organizations to sustain the educational mission of academic faculty within a viable delivery system; (5) satisfaction of managed care providers with graduates of academic medical centers, as measured by the clinical skills of graduate physicians. The study findings showed little support among managed care plans for paying supplements to include faculty practices in a health care network. Most study participants from managed care systems and academic faculty practices identified limited competencies that are unique to academic centers. Moreover, managed care organizations were only willing to undertake limited restructuring at best to include faculty practices within their networks. General concern about the preparation of resident physicians (especially those in primary care disciplines) for practice within contemporary managed care organizations existed among managed care informants. The results of the study indicate that as traditional funding sources for medical education are reduced, schools require greater integration with managed care plans to enable academic medical centers and their faculties to continue promoting clinical enterprise.

The changing face of the leader.

Leadership theory has identified leadership as a process or skill of transformation of organizations and society. Managerial theorists have seen leadership as a role within management, and have argued from a distinctly organizational perspective. During the last decade, mental health executives have gravitated from the leadership is policy emphasis to one of management accommodation to major changes in the health environment. The most noteworthy of these changes has been the dominance of private markets in health and the introduction throughout the mental health services sector of management techniques of managed care. Leadership is once again ascendant as a result of the failure of several of these initiatives, notably prior authorization of care, and a renewed public policy emphasis on needs of persons who are mentally ill. Major opportunities confronting the contemporary leader/manager include advocacy, diversity, and information management.

Health manpower oversupply: implications for physicians, nurse practitioners and physician assistants. A model.

Development of health manpower can no longer be viewed as an isolated educational problem apart from broader socio-economic considerations. This development results in changes in roles and relationships between professional groups and causes a redefinition of scope of practice and corresponding manpower requirements. A clear example of this thesis is the current redefinition of roles of nurse practitioners and physician assistants as the supply of physicians dramatically increases. The authors propose a general theoretical model based upon the biological sciences which may be used to predict future intraprofessional definitions of scope of practice in other areas. As hospitals and healthcare organizations undertake professional manpower planning on an increasingly organized basis, such projections will increase in significance for policy matters.

The oversupply of physicians: implications for hospital planning.

In the next ten years, hospitals will have to contend with the impact of group practice, which often competes with hospital-based services. How will a new interdependence between hospitals and group practices affect hospitals' strategic planning?

The gerontological imagination: social influences on the development of gerontology, 1945-present.

This article presents a framework for the analysis of the development of gerontology since 1945. Three distinct historical periods and several forces that have shaped the field are examined. These forces reside in the political, economic, sociocultural, technological, and knowledge realms of society. An analysis of the continuities and discontinuities over time provides a contrast between the historical periods identified. Despite the ideology of a continuous linear disciplinary progression, we find that discontinuities have been increasingly significant in shaping the experience of aging. Yet the field of gerontology lags in reflecting many of these changes. This incongruity calls the field to reassess its paradigmatic foundations and the empirical and theoretical work conducted within them. The implications for the disciplines and practice of gerontology are explored through a review of C. Wright Mills' contribution to a revival of the "gerontological imagination."